Download How to draw blood for establishing cell lines at NCRAD

NCRAD Biological Sample Form
NIFD Study
Please complete this form when sending blood to NCRAD. The form can be completed on
your computer and submitted electronically by an email attachment or can be completed by
hand and faxed. Use the Tab key to move to the next field. The contact information for
emailing or faxing the form is in the box below. Please email or fax the form as soon as
possible after the blood is drawn. NCRAD would like to receive this form before the blood
arrives.
To:
Kelley Faber
Phone: 1-800-526-2839
FAX:
1-317-278-1100
Phone: 1-317-274-7360
From:
Center:
Phone:
Fax:
Email:
Date:
Site #:
Individual #:
Email: [email protected]
Gender:
Birth Year:
Race:
American Indian/Alaska Native
Asian
Black or African American
More than one Race
Native Hawaiian or other Pacific Islander
Unknown
White
Ethnicity:
Hispanic or Latino
NonHispanic or Latino
Unknown
Date blood drawn:
FedEx tracking #:
For internal NCRAD use only, do not complete.
Kit#: __________
Volume(ml): Yellow _____